Stuart Kaufman, Cal Matsumoto, Juan Guerra, Raffaele Girlanda, Paige Parady, Cheryl Little, Erin Fennelly, Clara Torres, Eddie Island, Thomas Fishbein

Transplant Institute, Georgetown University Hospital, Washington, DC, United States

Recent experience demonstrates that administration of omega-3 fatty acid-based intravenous lipid emulsion (O3FA) in a dose of 1 g/kg/day can resolve hyperbilirubinemia associated with parenteral nutrition in intestinal failure (IFALD). However, reversal of cholestasis does not guarantee that other features of IFALD, specifically, hepatic fibrosis, shall resolve in the same manner. When patients with intestinal failure have an indication for transplantation, indications of portal hypertension presumably due to advanced bridging fibrosis or cirrhosis customarily indicate inclusion of a liver graft with intestine because of the risk of decompensation of a fibrotic liver due to transplantation surgery per se or because of post-operative complications. Herein, we report our experience with intestinal transplantation (ITx) of 5 patients treated with O3FA before surgery. Four of the 5 received a liver-inclusive graft and the other, an isolated ITx. For the 4 recipients of a liver-inclusive graft, median age at ITx was 20 months (range 14-59 months), all with short gut (1 re-transplant). Duration of O3FA was 453 ± 280 days. Laboratory values are pre-O3FA vs. at transplant; total bilirubin: 14.0±7.7 vs. 0.9±0.3 mg/dL, platelets: 176±562 vs. 152±59 K/µL, AST: 345±284 vs. 171±55 IU/L, and ALT: 224±223 vs. 174±41 IU/L. Explant histology indicated advanced bridging fibrosis in all 4. A single patient with NEC was initially listed for a liver/intestine transplant (total bilirubin of 7.4 mg/dL, platelets 163 K/µL), started O3FA at age 4 months, resolved cholestasis within 6 months, and received an isolated ITX at 19 months (total bilirubin: 0.5 mg/dL, platelets: 210 K/µL). Average follow up time is 44.8 months with all patients alive.

Conclusion: Administration of O3FA produced a significant reduction in cholestasis in 5 patients but reversed or prevented advanced liver disease in only 1 of the 5. Whether earlier initiation of O3FA would prevent advanced fibrosis and permit isolated ITx when indicated remains to be determined.